| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,332 |
2,332 |
$90K |
| D1206 |
Topical application of fluoride varnish |
2,556 |
2,556 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,603 |
2,603 |
$68K |
| D0272 |
Bitewings - two radiographic images |
1,334 |
1,333 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
102 |
$16K |
| D1110 |
Prophylaxis - adult |
170 |
170 |
$9K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
111 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$819.00 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$598.78 |
| D0240 |
|
13 |
13 |
$340.34 |